Treating erectile dysfunction and incontinence

 | March 1, 2008

Treating erectile dysfunction and incontinence

Incontinence and erectile dysfunction are common side effects of prostate disease and its treatment. Surgical techniques, such as nerve-sparing prostatectomy (see "Reducing side effects of surgery"), and more precise radiation therapies, have reduced but not eliminated these effects. Living with erectile dysfunction or incontinence is never easy. However, treatments are available that may improve, if not cure, these conditions. See your urologist for an evaluation of the cause and severity of your condition and find out what he or she suggests. Most men can find a solution that will make the problem more manageable.

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Erectile dysfunction

Surgery for prostate cancer can sever some of the nerves and arteries that are necessary for an erection. About three-quarters of men who have radical prostatectomy, including the nerve-sparing operations, experience erectile dysfunction (ED). The specific risk for surgery-induced ED depends on a number of variables, including the patient's age and the surgeon's skill. And regardless of the type of prostatectomy performed, men who do regain potency do so about six to 12 months following surgery.

Radiation therapy for prostate cancer can also harm erectile tissues. Erectile dysfunction is a side effect for roughly 40% to 50% of men who have external beam radiation and for about 30% who undergo brachytherapy. Even prostate cancer itself, in its advanced stages, can spread to the nerves and arteries necessary for an erection.

For men with prostate enlargement, finasteride, the antitestosterone drug used to treat BPH, has been linked to ED in 3.7% of patients and to a diminished libido in 3.3%.

Many men are fearful or anxious about their first sexual experience after prostate disease treatment. As a result, they may avoid intimacy, touch, and sexual activity. Similarly, their sexual partners may be reluctant to initiate any activity that could be perceived as pressuring.

The first step in such situations is to communicate. Talk with your spouse or sexual partner in order to begin dealing with these anxieties. Many couples find it difficult to discuss their sexual relationship, but failing to do so often worsens any potential dysfunction. And if a problem exists, researchers have found that the better a couple is at communicating with one another, the greater success they are likely to achieve through treatment.

Patients and their partners may also want to discuss their concerns with their doctor or other qualified health professional. In fact, it's important to see your doctor if you experience frequent or consistent impotence after prostate disease. Because your physician will know your medical history, you probably won't have to waste much time determining the cause of your ED. Instead, you can skip right to treatment. A specialist is rarely required. Impotence can be treated with any one of the techniques that help men who are unable to achieve erections for other reasons (see Table 12).

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PDE5 inhibitors: Viagra, Levitra, Cialis

Dubbed the impotence pill, sildenafil (Viagra) transformed the treatment of ED in the late 1990s. Since then, two similar drugs have become available, vardenafil (Levitra) and tadalafil (Cialis). These drugs are easy to use and have proved very effective for a broad range of ED, helping 60% to 70% of men who take them. They can be effective in treating ED related to radiotherapy for prostate cancer, nerve-sparing radical prostatectomy, and BPH medications.

These drugs aren't useful for treating ED that follows non-nerve-sparing or unsuccessful nerve-sparing radical prostatectomy, probably because the drug works on the same nerves that are destroyed or damaged during surgery. Even if the nerves are preserved, the drug is usually ineffective during the first six months after surgery or radiation therapy.

Despite some impressive results, these medications have their limitations. They're expensive, and some health insurance plans don't cover them or just cover a few pills per month. Also, they shouldn't be taken more than once a day, because they have the potential to cause dangerously low blood pressure. This drop is especially severe when the drug interacts with nitrate drugs, such as nitroglycerin, taken for heart disease. You should not take these drugs if you are taking nitrites. Men who take certain alpha blockers that tend to lower blood pressure also need to exercise caution. Indeed, all men with heart disease should use caution with these drugs because of their tendency to lower blood pressure. If you take an ED drug and go to the hospital with heart attack symptoms, it's imperative that you tell the health care team that you've taken this drug.

Short-term side effects include headache, flushing, upset stomach, and nasal congestion. Temporary disturbances in color vision have also been reported.

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Yohimbine (Yocon)

This was the first impotence pill approved by the FDA, and, at least until Viagra came out, it was widely prescribed. It's a chemical extract from the bark of the yohimbe tree, and is thought to help blood flow into the penis and prevent it from leaving too quickly. Studies have found it about 40% effective. Because of its relatively low success rate, it isn't recommended as a first-line treatment. However, it's still worth trying for men who can't take medications like Viagra. Side effects include increased heart rate and blood pressure, nervousness, irritability, and dizziness.

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Injectable drugs

Injectable drugs aren't as easy as swallowing a pill, and the idea may be disconcerting at first, but men who can't take medications such as Viagra, or who find such drugs ineffective, can often achieve an erection after injecting one or more prescription drugs into the penis. This therapy is more effective than Viagra for men whose ED is related to radical prostatectomy.

There are several such drugs, all of which work by relaxing the smooth muscle tissue of the penis, permitting adequate blood flow for an erection. The only injectable drug specifically approved for erectile dysfunction is alprostadil (Caverject and Edex). However, phentolamine (Regitine), which was approved for another use, is also effective for ED, as are drug combinations such as papaverine, phentolamine, and prostaglandin.

An erection usually occurs within five to 20 minutes of an injection and lasts 30 to 60 minutes. The main side effects are mild to moderate pain, bruising, or scarring. Like Viagra, these drugs can cause low blood pressure. Another rare complication is priapism, an erection that lasts too long. Any man who has an erection for more than three hours after an injection should go to the emergency room to receive a counteracting drug. Not doing so could result in permanent impotence.

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Drug pellets (MUSE)

As an alternative to injection, alprostadil is also available as tiny pellets that can be inserted into the penis shortly before intercourse (see Figure 10). These pellets are part of a therapy called medicated urethral system for erection, but your doctor will probably use the acronym MUSE.

This therapy involves inserting a pellet about an inch into the penis, using a disposable plastic applicator. From there, the surrounding tissue quickly absorbs the drug. Some men find MUSE easier to use than injections, but about 10% of them find the application mildly painful, and about 3% become dizzy and develop low blood pressure. Men should not use MUSE more than twice in 24 hours.

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Vacuum pump

External vacuum pump therapy can produce an erection without drugs or surgery. An airtight plastic cylinder attached to a handheld pump is placed over the penis just before intercourse. Some pumps are manual, while others operate on a battery. Pumping the air out creates a vacuum that draws blood into the organ, producing an erection. A constricting rubber ring placed around the base of the penis maintains the erection after the device is removed. Using a vacuum pump requires a certain amount of dexterity. Side effects may include pain, numbness, or bruising.

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Incontinence

Incontinence, the involuntary leakage of urine, is the other common and embarrassing side effect of prostate disease and its treatment. For men who have had a prostatectomy, the leakage of urine is a frequent side effect but subsides gradually over the first two years following surgery. For men who have had radiation therapy, urinary problems may take the form of irritation during urination.

If you experience urinary problems following prostate treatment, your doctor may recommend a urodynamic evaluation — a diagnostic session to help determine the nerve and muscle function of your bladder and urethral sphincter. This will help pinpoint the exact nature of the problem so that your therapy can be specifically designed to address it.

Stress incontinence is characterized by the leaking of small amounts of urine when you cough, sneeze, lift a heavy object, exercise, or otherwise put pressure on your bladder. One cause of stress incontinence is a weakened or damaged sphincter, the ringlike muscle that controls urine flow. Prostate surgery, such as TURP or prostatectomy, can cause such damage.

Urge incontinence occurs when the bladder develops a spasm. It suddenly contracts and expels urine. BPH seems to leave the bladder prone to such irritation.

Overflow incontinence is the result of partial obstruction, such as an enlarged prostate. Because the bladder cannot empty completely, urine may dribble frequently from the urethra. It may also occur when the bladder is severely weakened, which may also result from BPH if the bladder muscle becomes thick from straining to urinate.

Following treatment for BPH or prostate cancer, some men simply leak all the time.

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Treating incontinence

Before seeing your doctor, write down at least three days of urination habits. Note when the leaking occurred, what you were doing at the time, what appears to make the problem worse, and what appears to make the problem better. This will help your doctor determine the type or types of incontinence you have. Treatment varies according to type.

For stress incontinence, pelvic muscle exercises and biofeedback can help you sense your bladder filling, so you delay voiding until you reach a toilet. This technique has been found effective in some cases of incontinence following radical prostatectomy for prostate cancer. Pelvic floor exercises, also known as Kegel exercises, may help strengthen the muscles in this area and reduce stress incontinence.

Collagen implants are another option and can be effective for men who have undergone radical prostatectomy. Plastic surgeons use collagen, the protein that gives skin its tone, as a filler in cosmetic procedures. It can also be injected into the area once occupied by the prostate to provide support for the urethral muscles, so the patient doesn't lose urine as easily.

Some people with urge incontinence find that retraining the bladder is effective. This technique involves increasing the storage capacity of the bladder by learning to suppress sudden urges to urinate and by prolonging the interval between urinations.

The most effective drugs for urge incontinence are oxybutynin (Ditropan), tolterodine (Detrol), and some of the tricyclic antidepressants. For incontinence that results from treatments for prostate enlargement — such as TURP (see "Transurethral resection of the prostate"), which may produce bladder instability and urge incontinence — anticholinergic drugs such as propantheline (Pro-Banthine) and dicyclomine (Bentyl) may help.

Alpha blockers may improve overflow incontinence caused by BPH. These drugs help relax urethral muscles, decreasing urinary retention and the tendency to leak urine.

For more severe incontinence, there are several surgical procedures that can be performed to achieve dryness. One option is the surgical placement of an artificial sphincter (see Figure 11). In this procedure, a surgeon places a fluid-filled inflatable cuff around the urethra and a small pump in the scrotum. When inflated, the cuff squeezes the urethra tightly closed, preventing urine from escaping. When a man is ready to urinate, he squeezes the pump located in his scrotum, which deflates the cuff enough so that urine can flow. The cuff then reinflates on its own.

Bulbourethral sling surgery is another option for treating severe incontinence. The surgeon makes an incision between the scrotum and the rectum and installs a supportive sling under and around the urethra that is anchored to each side of the pelvic bone. By placing pressure on the urethra, the sling helps retain urine until the bladder fills. This is a challenging surgical procedure.

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Managing incontinence

Even if your incontinence can't be cured, it can still be managed. In addition to the treatments described above, absorbent underclothing is available that's no more bulky than normal underwear and can be worn easily under everyday clothing. Highly absorbent disposable pads are available in stores.

In another approach, a flexible tube (called an indwelling catheter) can be placed in the urethra to collect urine in a container. However, long-term catheterization, although sometimes necessary, creates many problems, including urinary infections. Finally, an external collecting device is another option. This device is fitted over the penis and connected to a drainage bag. With so many choices for managing incontinence, through trial and error, you may be able to find an option that works well for you.

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Review Date: 2008-03-01

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